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WAMNAL <br /> ANALYSIS RE EST AND Reference Document W 3 5 512 2 <br /> TE oOo N CHAIN OF CUSTODY RECORD* Page 1 of <br /> Project Name/No 1 c} (�''l M �-�_ _ _ Samples Shipment Date Z 1 5 3 _ Bill to 5 a, <br /> Sample Team Members z j�1 l L G + _ Lab Destination 8 fl-,x tc�:>11_ LfJ o n <br /> m <br /> Profit Center No 3 Lab Contacts <br /> t, <br /> Project Manager4 _ Project Contact/Phone 12 10 0 <br /> Report to - - <br /> Purchase Order No - _ _ Carrier/Waybill No 13 <br /> Required Report Date 11 101:16 U4:1111111ILM <br /> , t <br /> R <br /> u <br /> Sample 14 Sample 15 Date�me j fi 7Containerple Pre- 9 Requested Testing 20 Condition on 21 Disposa! 22 <br /> Number �escrt talon/T Collected me servatme Program Receipt Record No <br /> Sty 5�`I Z " <br /> t t I xyo�� IleL ti�TKE <br /> z <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal 25 <br /> Non-hazard J Flammable 'J Skin Irritant J Polson B J Unknown _J Return to Client IJ Disposal by Lab',,,J Archive (mos ) <br /> Turnaround Time Required 26 CC Level 27 <br /> Normal J Rush J I J !I J III 1J Project Specific [specify) _ <br /> 1 Relinquished by Date 3 1 Received by 28 (� C D to <br /> (Signature/Affiliation) Time (Signature/Aff bnon) me <br /> 2 Relinquished by Date 2 Received by Date <br /> (Signature/Affiliation) Time (Signature/Affiliation) Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signature/Affiliation) Time (Signature/Affiliation) Time <br /> Comments 29 <br /> MCA 3,1 SIq <br />